Every few years, I encounter a certain kind of wounded, fearful client who – in order to wiggle out of any vulnerability – attempts to hang onto their sense of power and privilege by insisting that the therapeutic fee makes therapy the equivalent of prostitution. Other clients are sure that the fee is hard, financial evidence that I do not and cannot care about them authentically – proof that it is “just my job” to “act” like I care. Some are sure that money changing hands means I am bound to agree with them, a paid endorsement of their behavior and fiscally insured admiration. Still others think that paying for therapy establishes the payer as a “loser” who has to buy friendship from me.

You are not paying me to pleasure you (therapy is rarely that pleasurable), like you, befriend you, cheerlead, or agree with you (I may or may not).

In fact, I will care about you for free. If I’ve taken your case, I’ve already determined that you are someone that I can care about. Forming a healthy, authentic alliance is a prerequisite to effective treatment. I simply don’t take cases if I can’t find solid empathic ground to stand on. If, after the first or second session, I don’t think that I can sustain my commitment to behave in a caring way toward you through dark and prickly times, I will make a referral to better-matched services.

This is what you are really paying for:
To keep my needs out of your way.

People often have a fantasy that my children, my husband, my parents, my friends are the real recipients of the selfless, apparently needless, one-sided nurturing that, in the office, I appear to be capable of providing. They aren’t. My husband suffers through my impossible, demanding, hungry-boring-selfish bits as steadfastly as I suffer through his. My children have to clean their rooms, help with chores, and deal with my impatience, irritability, and blind-spots. No one is getting for free what I try to provide in the office.

If we were friends, meeting once a week for a glass of wine during a rough patch, I would listen supportively about half the time and eventually, the next week – if not the very same night over the same drink – you’d have to give me equal air-time to blather on about the crap in my life.

When an acquaintance tries to tell me a long, detailed dream at a social function, I’m bored, burdened, looking for some way to extricate myself from the conversation as it is slips into a non-mutual place. Or perhaps, for a friend, I will patiently listen because I trust that they have been there for me, or will be in the future, through some equally self-absorbing struggle of my own. When clients tell me long, detailed dreams in my office, I’m fascinated. I’m absorbed, I’m going in deep – and amazed by the treasures I find there. I can offer up my intuition, suspending most of my interpersonal needs because, instead, my financial needs are being considered and that is how our relational equilibrium is maintained.

You are paying for therapy so that the discussion can continuously be all about you. So that I can, regularly and to the best of my ability, set aside my own shit to meet you on your terms. So that you don’t have to take care of me and immerse yourself in my life half the time. The fee is how you take care of me back. You owe me nothing beyond it. The fee is why our relationship is mutual. The fee compensates me for the inherent imbalance in the relationship. My needs are explicitly met there.

Obviously, I have the usual fixed business expenses of the self-employed that need to be covered so I do not accrue debt in the process of caring for others. My office rent, office liability and malpractice insurance, phone lines, office supplies, computing expenses, ongoing professional training and development, sick days, personal days, health insurance are factored out of the fee before I can begin to meet my family’s and my own needs for food, clothing, shelter, education and recreation.

Without the fee, I will come up against my own healthy boundaries, which will stop me from crossing the borders of my own needs for anything but short bursts of altruism. Explicit charity in all forms, emotional charity included, is tricky. All sacred texts talk about the importance of giving with anonymity – in a manner that can’t inflate the giver or disempower the receiver. Complicated, binding resentment emerges easily between known benefactors and their beneficiaries who are continuously involved with each other. Vast power differentials will emerge in any ongoing personal relationship that rests merely upon charitable impulses. Balance and mutuality are absolutely necessary in order for healthy intimacy to survive.

If the treatment is sometimes satisfying, gratifying, inspiring, warm, or pleasant for me, that is a nice perk, a tip perhaps – like the spare change that I sometimes find in the cracks between the cushions of my office couch.

But it’s not your job to keep me happy. It’s my job to invest my energies toward you, traveling all the way over to your universe of needs and wounds – and leave mine as far behind as I can. You are paying me to cross my boundaries consistently in ways that would be dangerously unstable, detrimental, masochistic, narcissistic, or avoidant if this relationship were taking place in my personal life. The fee protects me from pretending I am needless and perfected and generous. The fee protects you from primal indebtedness. The fee allows us both to explore symbolic and emotional dependencies over the long term, with safety and mutual self-respect.

The fee is the anchor that keeps us tethered to solid ground. Or perhaps it is better conceived of as ballast to keep the very real, but potentially lopsided intimacy of the therapeutic relationship balanced and afloat.

21 Comments

Yes – deep real caring is an earned by-product of creating an intimate working relationship together.
Very well put.

I think the fee is an issue because admiration, love, and trust are such imporant components, but not the entirety of the work, and the fee is at times experienced as an insult, a boundary, a marker. It implies to some of us as patients, at different stages of the work, that we are not being treated lovingly for “free”, as we are, because we are inherently deserving, and the fee itself can be experienced as a re-injury.

So well put!!!!! I love it! where else do you have such a “relationship” where the other person completely, with training, experience, education … is taught to leave out all his/her shit out and make it all about you?!?!?!? With genuine interest and care to provide you with insights into your blind spots, & support when you need it, even when you don’t know you need it? If that isn’t worthy enough to expect to make an investment, how about the “awakening”?? How about imagining that your shrink does this all day with all her other clients for “fun”? really? I don’t know why the fee in your profession is such an issue? In no other profession would one expect a freebe. I like to think of it this way, the mutual “caring” between my shrink & me is just a by-product of the hard earned work not what I’m paying for. Love your blog & I’ve just been introduced to it. Thanks for sharing!

This is an incredibly useful blog entry! As a client, I realize that being curious about how we feel about the financial aspect of therapy and how it relates to us can help lead to some fruitful discoveries….but this authentic description really helps to provide real understanding. Thank you for writing this!!

I think there are ways that therapy is a lop-sided space – and there are also ways in which is it co-created by two people matching energies. Some models of therapy are much more lopsided than others – seeing the therapist as having all the health – and lending their “healthy” ego to the “sick” patient. I wasn’t treated that way when I sought therapy many many years ago, and I don’t practice that way..

Thanks for reading John.
It seems to me that most of us, perhaps particularly those of us to come into psychotherapy practice through social work, feel highly conflicted about money – and there is little discussion in the training about the effect of the fee/salary (or lack of it) on the health of the clinician or the health of the therapeutic relationship itself. Glad this post was useful to you!
Martha

John Lee, LCSWSeptember 26, 2011 @ 3:32 am

i had never read or thought about our fees as you describe it. it totally makes sense, and makes me not feel guilty or awkward about conversations re: money and fees. look fwd to more insights

Thank you so much for your comments Christine. I find that the more information I give to my patients about the hows and whys of the therapeutic process, the more de-mystified the process becomes, and the more energized our alliance becomes. Laying this information out and sorting through it with many different clients has helped me immensely.
Best,
Martha

Thank you for your intelligent and insightful post. The financial side of therapy can be so problematic and is so rarely written about in such an intelligent way. You sound like a therapist I would like to work with.

Thanks Robin – Talking this through, sometimes many many times with clients has been very helpful – so many people come to therapy fearful that they cannont be loved, and the fee, and sometimes the therapeutic frame itself seems to serve as lingering proof of that they are unloveable, blocking their perceptions of therapists real affection/appreciation/admiration. Its important to explain to patients what the frame is for, and how it serves the intimacy in the relationship. Thanks for reading, and for the feedback!
Martha

wow! Martha– this was so perfectly put. I have only been able to articulate this need as “so I will not feel resentful”. You have really fleshed out the nuanced seen and hidden costs of this imbalanced relationship…. excellent. Again, a great post for any new or not-so-new therapist. We often, given our own caretaker natures get caught up in our own guilty confusions about what and how much we are supposed to provide–
thanks, Robin

Thank you, your support means a lot 🙂
It is a tenuous balance – and a fluid one – that requires regular reevaluation. Often therapists only talk about finances when they have problems collecting, or when financial hardship threatens to end a good therapy, or when fees need to be raised for external reasons. I find that it is helpful to talk to all clients about the realities and the symbolic meaning of money in the relationship. Even clients who pay easily, and regularly with no mention of the fee have deep projections about what the fee means about the relationship.
Glad its useful to you.